Provider Demographics
NPI:1770188849
Name:STATE OF DADE, LLC
Entity Type:Organization
Organization Name:STATE OF DADE, LLC
Other - Org Name:MAGNOLIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:423-718-8521
Mailing Address - Street 1:578 CLASSIC TRL
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-5895
Mailing Address - Country:US
Mailing Address - Phone:423-718-8521
Mailing Address - Fax:
Practice Address - Street 1:4626 BATTLEFIELD PARKWAY
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736
Practice Address - Country:US
Practice Address - Phone:706-841-0444
Practice Address - Fax:706-841-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy